Form 4 Public Health Passenger Locator Form

Public Health Passenger Locator Form: To protect your health, public health officers need you to complete this form whenever they
suspect a communicable disease onboard a flight. Your information will help public health officers to contact you if you were exposed to
a communicable disease. It is important to fill out this form completely and accurately. Your information is intended to be held in
accordance with applicable laws and used only for public health purposes.
~Thank you for helping us to protect your health.

One form should be completed by an adult member of each family. Print in capital (UPPERCASE) letters. Leave blank boxes for spaces.
FLIGHT INFORMATION:

1. Airline name

2. Flight number

3. Seat number

4. Date of arrival (yyyy/mm/dd)

2 0
PERSONAL INFORMATION: 5. Last (Family) Name

6. First (Given) Name

7. Middle Initial

8. Your sex
Male

Female

PHONE NUMBER(S) where you can be reached if needed. Include country code and city code.
9. Mobile

10. Business

11. Home

12. Other

13. Email address
PERMANENT ADDRESS:

14. Number and street (Separate number and street with blank box)

15. Apartment number

16. City

17. State/Province

18. Country

19. ZIP/Postal code

TEMPORARY ADDRESS: If you are a visitor, write only the first place where you will be staying.
20. Hotel name (if any)
21. Number and street (Separate number and street with blank box)

22. Apartment number

23. City

24. State/Province

25. Country

26. ZIP/Postal code

EMERGENCY CONTACT INFORMATION of someone who can reach you during the next 30 days
27. Last (Family) Name
28. First (Given) Name

30. Country

32. Mobile phone

29. City

31. Email

33. Other phone

34. TRAVEL COMPANIONS – FAMILY: Only include age if younger than 18 years
Last (Family) Name
First (Given) Name

Seat number

Age <18

(1)
(2)
(3)
(4)
35. TRAVEL COMPANIONS – NON-FAMILY: Also include name of group (if any)
Last (Family) Name
First (Given) Name
(1)
(2)

Group (tour, team, business, other)